Overview
Pulmonary artery catheter (PAC) insertion involves the placement of a specialized catheter through the right heart into the pulmonary artery to provide detailed hemodynamic monitoring. It measures cardiac output, pulmonary artery pressures, and mixed venous oxygen saturation.
PAC provides comprehensive hemodynamic data essential for managing critically ill patients, especially those with cardiogenic shock, severe heart failure, or complex cardiac surgery. It allows for precise titration of vasoactive medications and fluid therapy.
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Indications
Severe heart failure requiring precise hemodynamic monitoring
Complex cardiac procedures requiring detailed monitoring
Septic shock with hemodynamic instability
Pre and post-transplant monitoring
Assessment and monitoring of pulmonary pressures
Critically ill patients requiring detailed hemodynamics
Clinical research requiring hemodynamic data
Assessment of cardiac function and hemodynamics
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, cardiac function), equipment check (PAC kit, monitoring system, fluoroscopy), informed consent, and understanding the cardiac anatomy and catheter waveforms.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, check coagulation status, perform cardiac examination, and obtain informed consent. Position patient appropriately.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing contraindications
- Poor positioning
💡 Pro Tip:
Always check coagulation status and perform thorough cardiac examination before procedure.
Step 2: Equipment Setup
Prepare PAC kit, set up monitoring system, check fluoroscopy, and ensure sterile technique.
⚠️ Common Mistakes to Avoid:
- Broken equipment
- Poor sterile technique
- Inadequate monitoring
💡 Pro Tip:
Always test the monitoring system and fluoroscopy before starting.
Step 3: Central Venous Access
Establish central venous access (internal jugular or subclavian) and insert introducer sheath.
⚠️ Common Mistakes to Avoid:
- Poor central access
- Wrong introducer size
- Inadequate hemostasis
💡 Pro Tip:
Use ultrasound guidance for central venous access. Ensure proper introducer size.
Step 4: Catheter Insertion
Insert PAC through introducer, advance through right atrium, right ventricle, and into pulmonary artery.
⚠️ Common Mistakes to Avoid:
- Wrong catheter positioning
- Arrhythmias
- Poor waveform interpretation
💡 Pro Tip:
Monitor ECG continuously during insertion. Watch for arrhythmias.
Step 5: Waveform Confirmation
Confirm catheter position using pressure waveforms: RA, RV, PA, and PCWP.
⚠️ Common Mistakes to Avoid:
- Wrong waveform interpretation
- Poor catheter positioning
- Inadequate confirmation
💡 Pro Tip:
Learn to recognize normal waveforms. PA waveform should show dicrotic notch.
Step 6: Balloon Inflation
Inflate balloon to obtain pulmonary capillary wedge pressure (PCWP).
⚠️ Common Mistakes to Avoid:
- Over-inflation
- Prolonged inflation
- Poor waveform
💡 Pro Tip:
Inflate balloon slowly. Never leave balloon inflated for more than 15 seconds.
Step 7: Position Confirmation
Confirm catheter position with chest X-ray, secure catheter, and begin monitoring.
⚠️ Common Mistakes to Avoid:
- No chest X-ray
- Poor catheter securing
- Inadequate monitoring
💡 Pro Tip:
Always obtain chest X-ray to confirm position and rule out complications.
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Post-procedure Care
Post-procedure care includes confirming catheter position with chest X-ray, monitoring for complications (arrhythmias, pulmonary artery rupture), securing the catheter, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Arrhythmias | 10-30% | Premature beats, ventricular tachycardia, complete heart block | Remove catheter, antiarrhythmics, temporary pacing if needed | Gentle technique, avoid prolonged manipulation, monitor ECG |
| Pulmonary artery rupture | 0.1-0.5% | Hemoptysis, chest pain, hypoxemia, hemothorax | Emergency thoracotomy, lung isolation, blood products | Gentle balloon inflation, avoid over-inflation, proper positioning |
| Infection | 3-8% | Fever, erythema at insertion site, positive blood cultures | Remove catheter, antibiotics, blood cultures | Strict aseptic technique, proper dressing, early removal |
| Thrombosis | 5-15% | Catheter dysfunction, pulmonary embolism, right heart thrombus | Remove catheter, anticoagulation, monitoring | Proper technique, early removal, prophylactic anticoagulation |
| Pneumothorax | 1-3% | Chest pain, dyspnea, decreased breath sounds | Chest X-ray, oxygen therapy, chest tube if large | Proper technique, ultrasound guidance, avoid deep insertion |
| Valvular injury | <0.1% | New murmur, heart failure, arrhythmias | Echocardiography, cardiology consultation, monitoring | Gentle technique, proper catheter size, avoid force |
Clinical Pearls
Monitor ECG continuously during insertion - arrhythmias are common.
Learn to recognize normal waveforms - RA, RV, PA, PCWP.
Never leave balloon inflated for more than 15 seconds - risk of PA rupture.
Always obtain chest X-ray after insertion - confirm position and rule out complications.
Document all hemodynamic data - trends are more important than single values.
Practice sterile technique religiously - PAC infections are serious.
Be prepared for complications - have emergency equipment ready.
Check catheter function regularly - thrombosis can develop quickly.
Use appropriate catheter size - too large increases complications.
Remove PAC as soon as possible to reduce complications.